Association of the low e' and high E/e' with long-term outcomes in patients with normal ejection fraction: a hospital population-based observational cohort study

Abstract

Objective: We aimed to evaluate the association of the severity of left ventricular (LV) diastolic dysfunction with long-term outcomes in patients with normal ejection fraction.

Design: Retrospective study.

Setting: A single centre in Japan.

Participants: We included 3576 patients who underwent both scheduled transthoracic echocardiography and ECG between 1 January and 31 December 2013, in a hospital-based population after excluding valvular diseases or low ejection fraction (<50%) or atrial fibrillation and categorised them into three groups: septal tissue Doppler early diastolic mitral annular velocity (e')≥7 (without relaxation disorder, n=1593), e'<7 and early mitral inflow velocity (E)/e'≤14 (with relaxation disorder and normal LV end-diastolic pressure, n=1337) and e'<7 and E/e'>14 (with relaxation disorder and high LV end-diastolic pressure, n=646).

Primary and secondary outcome measures: The primary outcome measure was a composite of all-cause death and major adverse cardiac events (MACE). The secondary outcome measure were all-cause death and MACE, separately.

Results: The cumulative 3-year incidences of the primary outcome measures were significantly higher in the e'<7 and E/e'≤14 (19.0%) and e'<7 and E/e'>14 group (23.4%) than those for the e'≥7 group (13.0%; p<0.001). After adjusting for confounders, the excess 3-year risk of primary outcome for the groups with e'<7 and E/e'≤14 related to e'≥7 (HR: 1.24; 95% CI 1.02 to 1.52) and e'<7 and E/e'>14 related to e'<7 (HR: 1.57; 95% CI 1.28 to 1.94) were significant. The severity of diastolic dysfunction was associated with incrementally higher risk for primary outcomes (p<0.001).

Conclusion: The severity of LV diastolic dysfunction using e'<7 and E/e'>14 was associated with the long-term prognosis in patients with normal ejection fraction in an incremental fashion.

Keywords: cardiology; diastolic dysfunction; echocardiography; preserved ejection fraction; retrospective.

Figure 1

Flowchart of the study population. AR,aortic regurgitation; AS, aortic stenosis; E, the transmitral Doppler earlyfilling velocity; e, transmitral Doppler early filling velocity; E′, the tissue Doppler early diastolic mitralannular velocity; LVEF, left ventricular ejection fraction; MR, mitralregurgitation; MS, mitral stenosis; TTE, transthoracic echocardiography.

Figure 2

Cumulative incidence of the primary outcome measure (a composite of all-cause death and MACE) and secondary outcomes measure (all cause death, MACE). (A) A composite of all cause death and MACE, (B) all cause death, (C) MACE. MACE defined as acute heart failure, acute myocardial infarction, unstable angina pectoris, cerebral infarction, cerebral haemorrhage, aortic dissection and treatment of aortic aneurysm. MACE, major adverse cardiac event.

Figure 3

Subgroup analyses. DM, diabetes mellitus; HT=hypertension; IHD, ischemic heart disease; CKD, chronic kidney disease.